Archive for April, 2010|Monthly archive page

The number of new plant species discovered in Borneo in the last three years outnumbers all the other categories combined. Sixty-seven new plants have been found, along with 29 invertebrates, 17 new species of fish, one bird, five amphibians and five reptiles reports WWF.

“You have some iconic small species which are very interesting to talk about but perhaps it’s the plants that are tremendously important in terms of potential future cures,” said David Norman, director of campaigns for the WWF.

Nature’s ‘treasure’ unearthed in Borneo

By Hilary Whiteman, CNN

Color-changing frogs, the world’s longest stick insect and a slug that shoots “love darts” are among the biological “treasure” discovered by scientists in the lush green heart of Borneo.

Scientists have found 123 new species of animals, insects and plants on the South East Asian island since the three governments that control the land signed a pact to safeguard its future in 2007.

The new species are on a list released Thursday by the World Wildlife Fund (WWF) to mark Earth Day and to raise awareness of the value of protecting areas rich in biodiversity.

“You have some iconic small species which are very interesting to talk about but perhaps it’s the plants that are tremendously important in terms of potential future cures,” said David Norman, director of campaigns for the WWF.

“About half of all synthetic drugs have a natural origin — these are commercial drugs based on plants and sometimes animals. So we can’t afford to lose species,” he said.

The number of new plant species discovered in Borneo in the last three years outnumbers all the other categories combined. Sixty-seven new plants have been found, along with 29 invertebrates, 17 new species of fish, one bird, five amphibians and five reptiles. The WWF describes the region as a “global treasure teeming with unique and extraordinary life.”

Some of the more unusual amphibians found there include color-changing frogs, which also fly.

Males of the species (Rhacophorus penanorum) are just 3.5 centimeters long and their skin changes from bright green during the night to brown during the day. They can be found living in trees in the Tapin Valley within the Gunung Mulu National Park in Sarawak. Their fully-webbed feet allow them to glide for up to 15 meters from tree branch to tree branch.

The tail of the long-tailed slug (Ibycus rachelae) is three-times the length of its head, allowing it to curl up to sleep. More unusually, when it mates the slug fires a so-called “love dart” made of calcium carbonate that injects a hormone into its prospective partner to increase the chances of reproduction.

The world’s longest-stick insect (Phobaeticus chani) is more than half a meter long and lives high up in the rainforest canopy. “Only three specimens have ever been discovered. It’s quite extraordinary that it’s been there for so long — you wouldn’t miss it if it landed on you,” Norman said.

The rate of the discovery of new species has increased since 2007 when the governments of Indonesia, Malaysia and Brunei signed an agreement to conserve the area.

The agreement covers a 220,000 square kilometre tract of land that straddles all three countries which is known as the Heart of Borneo.

“This not just a nature reserve. There are lots of people who live there. Farming goes on there. There is eco-tourism. These are all things that must continue. The point is to ensure that the value of the forest standing is much greater than the value of it being cut down,” Norman said.

The WWF says the Heart of Borneo Declaration has worked to conserve the environment by exerting pressure on governments, developers and industry to adapt their plans to minimize their impact on the land.

It credits the agreement with preventing the destruction of two million hectares of rainforest to create the world’s largest palm oil plantation. Plans to build a road through the middle of the region in 2007 were also shelved for environmental reasons.

“About half of all the land in the heart of Borneo lies in private hands. It’s so remote you can’t possibly enforce this, so this is very much about negotiating agreements. Whenever there is a new proposal for a new road or a new farm or a new plantation or a new mine, it is worked through in the context of the agreement that was signed in 2007,” Norman said.

Meanwhile, scientists are still busy surveying the tangled mass of plants, animals and insects that thrive in the hot, humid conditions of the Borneo rainforest. The WWF says it is impossible to predict how many more new species will be found.

“It is so difficult to know how many species there are on the planet. Scientists sometimes estimate maybe there are 10 million species in total out there and we’ve only described 1.7 million of them so far,” Norman said.

The purposes of these Guidelines are to (1) optimize pain control, recognizing that a pain-free state may not be attainable; (2) enhance functional abilities and physical and psychologic well-being; (3) enhance the quality of life of patients; and (4) minimize adverse outcomes.

Focus

These Guidelines focus on the knowledge base, skills, and range of interventions that are the essential elements of effective management of chronic pain and pain-related problems. The Guidelines recognize that the management of chronic pain occurs within the broader context of health care, including psychosocial function and quality of life. These Guidelines apply to patients with chronic noncancer neuropathic, somatic (e.g., myofascial), or visceral pain syndromes. The Guidelines do not apply to patients with acute pain from an injury or postoperative recovery, cancer pain, degenerative major joint disease pain, headache syndromes (e.g., migraine and cluster), temporomandibular joint syndrome, or trigeminal or other neuralgias of the head or face. In addition, the Guidelines do not apply to pediatric patients and do not address the administration of intravenous drugs or surgical interventions other than implanted intrathecal drug delivery systems and nerve stimulators.

Application

These Guidelines are intended for use by anesthesiologists and other physicians serving as pain medicine specialists. The Guidelines recognize that all anesthesiologists or other physicians may not have access to the same knowledge base, skills, or range of modalities. However, aspects of the Guidelines may be helpful to anesthesiologists or other physicians who manage patients with chronic pain in a variety of practice settings. They may also serve as a resource for other physicians, nurses, and healthcare providers (e.g., rehabilitation therapists, psychologists, and counselors) engaged in the care of patients with chronic pain. They are not intended to provide treatment algorithms for specific pain syndromes.

Summary of RecommendationsI. Patient Evaluation

* All patients presenting with chronic pain should have a documented history and physical examination and an assessment that ultimately supports a chosen treatment strategy.

○History:

▪ A pain history should include a general medical history with emphasis on the chronology and symptomatology of the presenting complaints.

▪ A history of current illness should include information about the onset, quality, intensity, distribution, duration, course, and sensory and affective components of the pain and details about exacerbating and relieving factors.

▪ Information regarding previous diagnostic tests, results of previous therapies, and current therapies should be reviewed by the physician.

▪ In addition to a history of current illness, the history should include (1) a review of available records, (2) medical history, (3) surgical history, (4) social history including substance use or misuse, (5) family history, (6) history of allergies, (7) current medications including use or misuse, and (8) review of systems.

▪ The causes as well as the effects of pain (e.g., physical deconditioning, change in occupational status, and psychosocial dysfunction) and the impacts of previous treatment(s) should be evaluated and documented.

○ Physical examination: The physical examination should include an appropriately directed neurologic and musculoskeletal evaluation, with attention to other systems as indicated.

○ Psychosocial evaluation: The psychosocial evaluation should include information about the presence of psychologic symptoms (e.g., anxiety, depression, or anger), psychiatric disorders, personality traits or states, and coping mechanisms.

▪ An assessment should be made of the impact of chronic pain on a patient’s ability to perform activities of daily living.

▪ An evaluation of the influence of pain and treatment on mood, ability to sleep, addictive or aberrant behavior, and interpersonal relationships should be performed.

▪ Evidence of family, vocational, or legal issues and involvement of rehabilitation agencies should be noted.

▪ The expectations of the patient, significant others, employer, attorney, and other agencies may also be considered.

○ Interventional diagnostic procedures: Appropriate diagnostic procedures may be conducted as part of a patient’s evaluation, based on a patient’s clinical presentation.

▪ The choice of an interventional diagnostic procedure (e.g., selective nerve root blocks, medial branch blocks, facet joint injections, sacroiliac joint injections, and provocative discography) should be based on the patient’s specific history and physical examination and anticipated course of treatment.

▪ Interventional diagnostic procedures should be performed with appropriate image guidance.

▪ Diagnostic medial branch blocks or facet joint injections may be considered for patients with suspected facet-mediated pain to screen for subsequent therapeutic procedures.

▪ Diagnostic sacroiliac joint injections or lateral branch blocks may be considered for the evaluation of patients with suspected sacroiliac joint pain.

▪ Diagnostic selective nerve root blocks may be considered to further evaluate the anatomic level of radicular pain.

▪ The use of sympathetic blocks may be considered to support the diagnosis of sympathetically maintained pain.

▪ They should not be used to predict the outcome of surgical, chemical, or radiofrequency sympathectomy.

▪ Peripheral blocks may be considered to assist in the diagnosis of pain in a specific peripheral nerve distribution.

▪ Provocative discography may be considered for the evaluation of selected patients with suspected discogenic pain.

▪ Provocative discography should not be used for the routine evaluation of the patient with chronic nonspecific back pain.

* Findings from the patient history, physical examination, and diagnostic evaluation should be combined to provide the foundation for an individualized treatment plan focused on the optimization of the risk–benefit ratio with an appropriate progression of treatment from a lesser to greater degree of invasiveness.

* Whenever possible, direct and ongoing contact should be made and maintained with the other physicians caring for the patient to ensure optimal care management.

Multimodal or Multidisciplinary Interventions

* Multimodal interventions should be part of a treatment strategy for patients with chronic pain.

* A long-term approach that includes periodic follow-up evaluations should be developed and implemented as part of the overall treatment strategy.

* When available, multidisciplinary programs may be used.

Single Modality Interventions

* Ablative techniques (other treatment modalities should be attempted before consideration of the use of ablative techniques):

○ Chemical denervation (e.g., alcohol, phenol, or high concentration local anesthetics) should not be used in the routine care of patients with chronic noncancer pain.

○ Cryoablation may be used in the care of selected patients (e.g., postthoracotomy pain syndrome, low back pain [medial branch], and peripheral nerve pain).

○ Thermal intradiscal procedures: IDET may be considered for young, active patients with early single-level degenerative disc disease with well-maintained disc height.

○ Radiofrequency ablation:

▪ Conventional (e.g., 80°C) or thermal (e.g., 67°C) radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections of the joint or medial branch nerve have provided temporary relief.

▪ Conventional radiofrequency ablation may be performed for neck pain.

▪ Water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain.

▪ Conventional or other thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of lumbar radicular pain.

* Acupuncture: Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, noninflammatory low back pain.

* Blocks:

○ Joint blocks:

▪ Intraarticular facet joint injections may be used for the symptomatic relief of facet-mediated pain.

▪ Sacroiliac joint injections may be considered for the symptomatic relief of sacroiliac joint pain.

○ Nerve and nerve root blocks:

▪ Celiac plexus blocks using local anesthetics with or without steroids may be used for the treatment of pain secondary to chronic pancreatitis.

▪ Lumbar sympathetic blocks or stellate ganglion blocks may be used as components of the multimodal treatment of CRPS if used in the presence of consistent improvement and increasing duration of pain relief.

▪ Sympathetic nerve blocks should not be used for the long-term treatment of non-CRPS neuropathic pain.

▪ Medial branch blocks may be used for the treatment of facet-mediated spine pain.

▪ Peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain.

* Botulinum toxin:

○ Botulinum toxin should not be used in the routine care of patients with myofascial pain.

○ Botulinum toxin may be used as an adjunct for the treatment of piriformis syndrome.

* Electrical nerve stimulation:

○ Neuromodulation with electrical stimulus:

▪ Subcutaneous peripheral nerve stimulation: Subcutaneous peripheral nerve stimulation may be used in the multimodal treatment of patients with painful peripheral nerve injuries who have not responded to other therapies.

▪ Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies.

* Spinal cord stimulation may also be considered for other selected patients (e.g., CRPS, peripheral neuropathic pain, peripheral vascular disease, and postherpetic neuralgia).

○ Anticonvulsants: Anticonvulsants (e.g.,α-2-delta calcium-channel antagonists, sodium-channel antagonists, and membrane-stabilizing drugs) should be used as part of a multimodal strategy for patients with neuropathic pain.

○ Antidepressants:

▪ Tricyclic antidepressants should be used as part of a multimodal strategy for patients with chronic pain.

▪ Serotonin–norepinephrine reuptake inhibitors should be used as part of a multimodal strategy for a variety of chronic pain patients.

▪ Selective serotonin reuptake inhibitors may be considered specifically for patients with diabetic neuropathy.

○ Other drugs:

▪ As part of a multimodal pain management strategy, extended-release oral opioids should be used for neuropathic or back pain patients, and transdermal, sublingual, and immediate-release oral opioids may be used.

○ A strategy for monitoring and managing side effects, adverse effects, and compliance should be considered for all patients undergoing any long-term pharmacologic therapy.

* Physical or restorative therapy:

○ Physical or restorative therapy may be used as part of a multimodal strategy for patients with low back pain.

○ Physical or restorative therapy may be considered for other chronic pain conditions.

* Psychological treatment:

○ Cognitive behavioral therapy, biofeedback, or relaxation training: These interventions may be used as part of a multimodal strategy for patients with low back pain, as well as for other chronic pain conditions.

○ Supportive psychotherapy, group therapy, or counseling: These interventions may be considered as part of a multimodal strategy for chronic pain management.

* Trigger point injections: These injections may be considered for treatment of myofascial pain as part of a multimodal approach to pain management.

For these Guidelines, a literature review was used in combination with opinions obtained from expert consultants and other sources (e.g., ASA members, ASRA members, open forums, and Internet postings). Both the literature review and opinion data were based on evidence linkages or statements regarding potential relationships between clinical interventions and outcomes. The interventions listed below were examined to assess their impact on a variety of outcomes related to chronic noncancer pain.Cited Here…

Fernandez-Espejo and colleagues suggested that the endocannabinoid system is altered in schizophrenia and that dysregulation of this system, perhaps induced by exogenous cannabis, can interact with neurotransmitter systems in a way so that a “cannabinoid hypothesis” can be integrated with other neurobiologic hypotheses (eg, those involving dopamine and glutamate).

Evidence Accumulates for Links Between Marijuana and Psychosis

Michael T. Compton, MD, MPH

Introduction

A number of studies in recent years have revealed complex links between marijuana use and psychotic symptoms and diagnosable psychotic disorders like schizophrenia. Although a thorough review of this broad literature is beyond the purview of this brief communication, two avenues of research will be succinctly summarized, pertaining to (1) associations between cannabis use and clinical manifestations of psychosis, and (2) the biologic plausibility of the observed links.

Cannabis and Psychosis

Diverse studies suggest that cannabis use is associated with psychotic phenomenology. First, in addition to being the most abused illicit substance in the general US population, cannabis is clearly the most abused illegal drug among individuals with schizophrenia.[1,2] Furthermore, the initiation of cannabis use among those with psychotic disorders often precedes the onset of psychosis by several years.[1,3,4]

Second, cannabis use in adolescence is increasingly recognized as an independent risk factor for psychosis and schizophrenia.[5-7] That is, several epidemiologic studies suggest that cannabis use is a component cause of schizophrenia.[8,9]

Very recently, McGrath and colleagues[10] reported that early cannabis use is associated with psychosis-related outcomes (having a nonaffective psychotic disorder, scoring in the highest quartile of the Peters Delusions Inventory,[11] and reporting hallucinations) in a cohort of 3801 individuals assessed at age 18-23 years. Findings among 228 sibling pairs in that study reduce the likelihood that unmeasured confounding variables account for the results.[10]

Third, cannabis use may interact with genetic factors to elevate risk for psychotic disorders. One sentinel study demonstrated that the catechol-O-methyltransferase Val158Met functional polymorphism moderates the effects of adolescent-onset cannabis use on the later development of psychosis.[12]

Fourth, preliminary research suggests that cannabis use before the manifestation of psychiatric symptoms may be associated with an earlier age at onset of psychotic symptoms,[13] and perhaps even an earlier onset of prodromal symptoms.[14] We found that simply classifying first-episode psychosis patients according to their maximum frequency of use before onset of psychotic symptoms (ie, categorizing into none, ever, weekly, or daily use) revealed no significant effects of cannabis use on risk for onset, but analyzing the change in frequency of use before onset (using time-dependent covariates), revealed that progression to daily cannabis use was associated with age at onset.[14]

Fifth, aside from studies linking cannabis use and psychotic disorders, an increasing body of research suggests a potential association between cannabis use and schizotypal symptoms, or psychosis-proneness, in the general population.[15,16]

Several lines of evidence support the potential biologic plausibility of these links between cannabis use and psychosis.

First, exogenous (eg, Δ-9-tetrahydrocannabinol) and endogenous cannabinoids (eg, anandamide) exert their effects (such as modulating the release of neurotransmitters including dopamine and glutamate) by interactions with specific cannabinoid (CB1) receptors that are distributed in brain regions implicated in schizophrenia.

Second, several studies have shown an increased CB1 receptor density in brain regions of interest in schizophrenia, including the dorsolateral prefrontal cortex and the anterior cingulate cortex.[17,18]

Third, other studies report elevated levels of endogenous cannabinoids in the blood and cerebrospinal fluid of patients with schizophrenia.[19-21]

In summarizing these and many other findings, Fernandez-Espejo and colleagues[23] have suggested that the endocannabinoid system is altered in schizophrenia and that dysregulation of this system, perhaps induced by exogenous cannabis, can interact with neurotransmitter systems in a way so that a “cannabinoid hypothesis” can be integrated with other neurobiologic hypotheses (eg, those involving dopamine and glutamate).

Conclusion

In sum, a growing body of clinical and epidemiologic research suggests significant but complex links between cannabis use and psychosis. Concurrently, ongoing neurobiologic research is revealing findings in the endocannabinoid system that appear to support the biologic plausibility of such links. It should be noted that much of the research conducted to date does not allow for causal determinations. Ongoing research of varying designs will undoubtedly enlighten the field.